6 NURSING CARE PLAN

Assessment

Priority Nursing Diagnosis 

Planning 

Nursing intervention 

Rationale 

Evaluation 

Subjective: 

Patient complaints of chest pain radiating on both shoulder. 

Objective: 

Restlessness 

Facial grimacing 

Pain scale of 10/10 

BP: 

HR: 

RR: 

Acute (chest) pain related to myocardial ischemia as evidence by patient reports pain and restlessness 

Within 1 hour of nursing interventions, patient will have improved comfort and relief in chest  

Established rapport. 

1.

 
1.

Assessed characteristic of chest pain, including location, intensity, radiation, and have patient rate pain from scale of 1-10 

2.

 
1.

Reviewed history of the pain. 

2.
 
 
1.

Maintained patient on bed rest and maintained relaxing environment 

2.
 
 
 
1.

Checked vital signs before narcotic medication and obtained 12 lead ECG  

2.
 
 
 
 
1.

Administered supplemental oxygen by means of nasal cannula or face mask, as indicated. 

2.
 
 
 
 
1.

Administered prescribe medication 

2.

·

administered loading dose of tab Aspirin and tab Brilinta as ordered 

·
 
 
 
·

administered pain medication as ordered 

·
·

Thrombolytic therapy 

 
1.
 Prepared patient for coronary angiography as ordered by MRP. 
2.
 
 
 

1. To gain patient trust (Linke et al. pg450). 

2. assessment helps in differentiating preexisting and current pain patterns.(zafari,2019). Variation appearance and behaviour focusing on the pain (Unruh et al. 909). . 

To provide baseline for comparison (Linke et al. pg499). 

4. Rest ruduce oxygen consumption and demand.To decrease external stimuli (Beltrão et al. and to decrease perception and response to pain (Linke et al. pg499). 

5. ECG record changes that can give evidence of cardiac damage and location of MI. (Zafari,2019) and to ascertain the presence on hypertension and respiratory depression (Linke et al. pg499) 

6. Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia (Unruh et al. 909). 

7. Aspirin is used to prevent clots which reduces risk of stroke and heart attack while Brillinta is an anti platelet. (Maes et al. pg2077) 

>Nitrates are useful for pain control by coronary vasodilating effects, which increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand. . (Maes et al. pg2077 

>thrombolytic therapy disolves the clot and improving blood flow. (Maes et al,pg2072) 

8. PCI is a treatment that uses catheter to place a stent to open up blood vessel thus improving blood flow. (sullivan,2018) 

>goal met; Patient had improved comfort as evidenced by patient able to rest, displays calmness and verbally states relieved of chest pain.